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Form SSA-632-BK (01-2018) UF
Discontinue Prior Editions Page 1 of 9
Social Security Administration OMB No. 0960-0037

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate

FOR SSA USE ONLY

ROAR Input Yes
We will use your answers on this form to decide if we can
No
waive collection of the overpayment or change the
amount you must pay us back each month. If we can't Input Date
waive collection, we may use this form to decide how you Waiver Approval
should repay the money.
Denial

SSI Yes No
Please answer the questions on this form as completely
as you can. We will help you fill out the form if you want. AMT OF OP $
If you are filling out this form for someone else, answer PERIOD (DATES) OF OP
the questions as they apply to that person.

1. A. Name of person on whose
record the overpayment occurred:

B. Social Security Number:

C. Name of overpaid person(s) making this request and his or her Social Security Number(s):

2. Check any of the following that apply. (Also, fill in the dollar amount in B, C, or D.)

A. The overpayment was not my fault and I cannot afford to pay the money back and/or it is
unfair for some other reasons.

B. I cannot afford to use all of my monthly benefit to pay back the overpayment. However I can
afford to have $ withheld each month.

C. I am no longer receiving Supplement Security Income (SSI) payments. I want to pay back
$ each month instead of paying all of the money at once.

D. I am receiving SSI payments. I want to pay back $ each month instead of
paying 10% of my total income.

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Form SSA-632-BK (01-2018) UF Page 2 of 9

SECTION I - INFORMATION ABOUT RECEIVING THE OVERPAYMENT

3. A. Did you, as representative payee, receive the overpaid benefits to use for the beneficiary?
Yes No (Skip to Question 4)

B. Name and address of the beneficiary

C. How were the overpaid benefits used?

4. If we are asking you to repay someone else's overpayment:

A. Was the overpaid person living with you when he/she was overpaid? Yes No

B. Did you receive any of the overpaid money? Yes No

C. Explain what you know about the overpayment AND why it was not your fault.

5. Why did you think you were due the overpaid money and why do you think you were not at fault in
causing the overpayment or accepting the money?

6. A. Did you tell us about the change or event that made you overpaid? If no, why
didn't you tell us? Yes No

B. If yes, how, when and where did you tell us? If you told us by phone or in person, who did you
talk with and what was said?

C. If you did not hear from us after your report, and/or your benefits did not
change, did you contact us again? Yes No

7. A. Have we ever overpaid you before? Yes No

If yes, on what Social Security number?
B. Why were you overpaid before? If the reason is similar to why you are overpaid now, explain
what you did to try to prevent the present overpayment.

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Form SSA-632-BK (01-2018) UF                                                                 Page 3 of 9

                                                                             FOR SSA USE ONLY
                                                             NAME:
SECTION II - YOUR FINANCIAL STATEMENT
                                                             SSN:
You need to complete this section if you are asking us either to waive the collection of the 
overpayment or to change the rate at which we asked you to repay it. Please answer all questions as 
fully and as carefully as possible. We may ask to see some documents to support your statements, so 
you should have them with you when you visit our office.

    EXAMPLES ARE:
         •  Current Rent or Mortgage Books            • 2 or 3 recent utility, medical, charge card, 
                                                        and insurance bills
         •  Savings Passbooks
                                                      • Canceled checks
         •  Pay Stubs
                                                      • Similar documents for your spouse or 
         •  Your most recent Tax Return                 dependent family members
Please write only whole dollar amounts-round any cents to the nearest dollar. If you need more space 
for answers, use the "Remarks" section at the bottom of page 7.
8.   A. Do you now have any of the overpaid checks or money in               Yes Amount:
      your possession (or in a savings or other type of account)?            No       Return this           
                                                                                 amount to SSA

     B. Did you have any of the overpaid checks or money in your             Yes Amount:
      possession (or in a savings or other type of account) at the 
      time you received the overpayment notice?                              No  Answer Question 9.

9. Explain why you believe you should not have to return this amount.

ANSWER 10 AND 11 ONLY IF THE OVERPAYMENT IS SUPPLEMENTAL SECURITY INCOME 
(SSI) PAYMENTS. IF NOT, SKIP TO 12.

10.   A. Did you lend or give away any property or cash after notification       Yes (Answer Part B)
         of the overpayment?
                                                                                 No (Go to question 11.)
      B. Who received it, relationship (if any), description and value:

11.   A. Did you receive or sell any property or receive any cash                Yes (Answer Part B)
         (other than earnings) after notification of this overpayment?
                                                                                 No (Go to question 12.)
      B. Describe property and sale price or amount of cash received:

12.   A. Are you now receiving cash public assistance 
                                                          Yes (Answer B and C and See note below)
         such as Supplemental Security Income     
         (SSI) payments?
                                                          No 

      B. Name or kind of public assistance                             C. Claim Number

IMPORTANT: If you answered "YES" to question 12, DO NOT answer any more questions on this 
form. Go to page 8, sign and date the form, and give your address and phone number(s). Bring or   
mail any papers that show you receive public assistance to your local Social Security office as soon   
as possible.

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Form SSA-632-BK (01-2018) UF                                                      Page 4 of 9

Members Of Household
13.  List any person (child, parent, friend, etc.) who depends on you for support AND who lives        
     with you.
                NAME              AGE                     RELATIONSHIP                                
                                        (If none, explain why the person is dependent on you)

Assets - Things You Have And Own

14.  A. How much money do you and any person(s) listed in question 13 above      $
     have as cash on hand, in a checking account, or otherwise readily available?

     B. Does your name, or that of any other member of your household 
     appear, either alone or with any other person, on any of the following?
                                                                            SHOW THE INCOME (interest, 
     TYPE OF ASSET                OWNER      BALANCE OR             PER     dividends) EARNED EACH 
                                                 VALUE     MONTH            MONTH. (If none, explain in spaces 
                                                                            below. If paid quarterly, divide by 3).
     SAVINGS (Bank, Savings and              $           $
     Loan, Credit Union)                     $           $
     CERTIFICATES OF DEPOSIT (CD)            $           $
     INDIVIDUAL RETIREMENT 
                                             $           $
     ACCOUNT (IRA)
     MONEY OR MUTUAL FUNDS                   $           $
     BONDS, STOCKS                           $           $
     TRUST FUND                              $           $
     CHECKING ACCOUNT                        $           $
     OTHER (EXPLAIN)                         $           $

                                  TOTALS $               $                     Enter the "Per Month" total 
                                                                               on line (k) of question 18.

15.  A. If you or a member of your household own a car, (other than the family vehicle), van, truck, 
     camper, motorcycle, or any other vehicle or a boat, list below.
                                                   PRESENT  LOAN BALANCE         MAIN PURPOSE    
               OWNER              YEAR/MAKE/MODEL
                                                   VALUE              (if any)    FOR USE
                                                 $         $
                                                 $         $
                                                 $         $
     B. If you or a member of your household own any real estate (buildings or land), OTHER than 
     where you live, or own or have an interest in, any business, property, or valuables,        
     describe below.
                                                   MARKET  LOAN BALANCE          USAGE-INCOME   
               OWNER              DESCRIPTION
                                                   VALUE              (if any)    (rent etc.)
                                                 $         $
                                                 $         $
                                                 $         $
                                                 $         $

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Form SSA-632-BK (01-2018) UF                                                                           Page 5 of 9

Monthly Household Income
If paid weekly, multiply by 4.33 (4 1/3) to figure monthly pay. If paid every 2 weeks, multiply by 2.166   
(2 1/6). If self-employed, enter 1/12 of net earnings. Enter monthly TAKE HOME amounts on line A of 
question 18 also.
16. A. Are you employed?                                  YES (Provide information below)  NO (Skip to B)
    Employer name, address, and phone: (Write "self" if self-employed) Monthly pay before           $
                                                                              deduction (Gross) 

                                                                             Monthly TAKE-          $
                                                                             HOME pay ( NET )

    B. Is your spouse employed?                           YES (Provide information below)  NO (Skip to C)

    Employer(s) name, address, and phone: (Write "self" if self-employed)    Monthly pay before  $
                                                                             deduction (Gross)

                                                                             Monthly TAKE-          $
                                                                             HOME pay (NET)
    C. Is any other person listed in     YES                      Name(s)
     Question 13 employed?               NO (Go to Question 17)
    Employer(s) name, address, and phone: (Write "self" if self-employed)    Monthly pay before  $
                                                                             deduction (Gross)
                                                                             Monthly TAKE- 
                                                                             HOME pay (NET)         $

17. A. Do you, your spouse or any dependent member of your household                                                              YES (Answer B)
     receive support or contributions from any person or organization?       NO  (Go to question 18)
    B. How much money is received each month?              $             SOURCE
     (Show this amount on line (J) of question 18)
BE SURE TO SHOW MONTHLY AMOUNTS BELOW - If received weekly or every 2 weeks, read the instruction at the top 
of this page.
18. INCOME FROM #16 AND #17 ABOVE                                                         OTHER        SSA USE 
    AND OTHER INCOME TO YOUR HOUSEHOLD                     YOURS \/ SPOUSE'S \/           HOUSEHOLD  \/
                                                                                          MEMBERS      ONLY
    A. TAKE HOME Pay (Net)                               $          $           $
     (From #16 A, B, C, above)
    B. Social Security Benefits

    C. Supplemental Security Income (SSI)

    D. Pension(s)           TYPE
     (VA, Military,        
     Civil  Service, 
     Railroad, etc.)        TYPE

    E. Public Assistance    TYPE
     (Other than SSI)
    F. Food Stamps (Show full face value of 
     stamps received )
    G. Income from real estate 
         (rent, etc.) (From question 15B)
    H. Room and/or Board Payments (Explain in 
     remarks below )

    I. Child Support/Alimony
    J. Other Support 
        (From #17 (B) above)
    K. Income From Assets (From question 14)

    L. Other (From any source, explain below)

    REMARKS                              TOTALS $                   $           $

                                                                             GRAND TOTAL $
                                                                      (Add 3 total blocks above)

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Form SSA-632-BK (01-2018) UF                                                      Page 6 of 9

Monthly Household Expenses
If the expense is paid weekly or every 2 weeks, read the instruction at the top of Page 5. Do NOT list 
an expense that is withheld from income (Such as Medical Insurance). Only take home pay is used to 
figure income.
                                                                                             SSA USE 
Show "CC" as the expense amount if the expense (such as clothing) is part of      $ PER MONTH
CREDIT CARD EXPENSE SHOWN ON LINE (F).                                                       ONLY
   A. Rent or Mortgage (If mortgage payment includes property or other    
19.
     local taxes, insurance, etc. DO NOT list again below.)
   B. Food (Groceries (include the value of food stamps) and food at 
     restaurants, work, etc.)

   C. Utilities (Gas, electric, telephone)

   D. Other Heating/Cooking Fuel (Oil, propane, coal, wood, etc.)

   E. Clothing

   F. Credit Card Payments (show minimum monthly payment allowed)

   G. Property Tax (State and local)

   H. Other taxes or fees related to your home (trash collection,                 
     water-sewer fees)
   I. Insurance (Life, health, fire, homeowner, renter, car, and any other 
     casualty or liability policies )

   J. Medical-Dental (After amount, if any, paid by insurance)

   K. Car operation and maintenance (Show any car loan payment in           
     (N) below)
   L. Other transportation

   M. Church-charity cash donations

   N. Loan, credit, lay-away payments (If payment amount is optional,      
     show minimum)

   O. Support to someone NOT in household (Show name, age, relationship 
     (if any) and address)

   P. Any expense not shown above (Specify)

   EXPENSE REMARKS (Also explain any unusual or very large           TOTAL $
   expenses, such as medical, college, etc.)

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Form SSA-632-BK (01-2018) UF Page 7 of 9

Income And Expenses Comparison

A. Monthly income (Write the amount here from the "Grand Total" of
20. $
#18.)

B. Monthly Expenses (Write the amount here from the "Total" of #19.) $

C. Adjusted Household Expenses +$25

D. Adjusted Monthly Expenses (Add (B) and (C)) $

If your expenses (D) are more than your income (A), explain FOR SSA USE ONLY
21.
how you are paying your bills.
INC. EXCEEDS $
ADJ EXPENSE +

INC LESS THAN $
ADJ EXPENSE -

Financial Expectation And Funds Availability

22. A. Do you, your spouse or any dependent member of your household expect YES (Explain
your or their financial situation to change (for the better or worse) in the on line below)
next 6 months? (For example: a tax refund, pay raise or full repayment of
a current bill for the better-major house repairs for the worse). NO

NO (Amount on hand)
B. If there is an amount of cash on hand or in checking
accounts shown in item 14A, is it being held for a NO (Money available for any use)
special purpose?
YES (Explain on line below)

YES (Explain
C. Is there any reason you CANNOT convert to cash the "Balance or Value"
on line below)
of any financial asset shown in item 14B.
NO

D. Is there any reason you CANNOT SELL or otherwise convert to cash any YES (Explain
of the assets shown in items 15A and B? on line below)
NO

Remarks Space – If you are continuing an answer to a question, please write the number (and letter,
if any) of the question first. (MORE SPACE ON NEXT PAGE)

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Form SSA-632-BK (01-2018) UF                                                   Page 8 of 9
REMARKS SPACE (Continued)

     PENALTY CLAUSE, CERTIFICATION AND PRIVACY ACT STATEMENT

I declare under penalty of perjury that I have examined all the information on this form, and on 
any accompanying statements or forms, and it is true and correct to the best of my knowledge.  
I understand that anyone who knowingly gives a false or misleading statement about a material 
fact in this information, or causes someone else to do so, commits a crime and may be sent to 
prison, or may face other penalties, or both.

     SIGNATURE OF OVERPAID PERSON OR REPRESENTATIVE PAYEE
SIGNATURE (First name, middle initial, last name) (Write in ink)
SIGN 
HERE
 DATE (Month, Day, Year)

WORK TELEPHONE NUMBER IF WE MAY CALL YOU AT WORK (Include area code)

HOME TELEPHONE NUMBER ( Include area code )

MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)

CITY AND STATE                                                         ZIP CODE

ENTER NAME OF COUNTY (IF ANY) IN WHICH YOU NOW LIVE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed    
by mark (X),two witnesses to the signing who know the individual must sign below, giving their 
full addresses.
SIGNATURE OF WITNESS                             SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State,         ADDRESS (Number and street, City, State,        
and ZIP Code)                                    and ZIP Code)

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Form SSA-632-BK (01-2018) UF Page 9 of 9

Privacy Act Statement
Collection and Use of Personal Information

Sections 204, 1631(b), and 1879 of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent an accurate and timely decision on your overpayment waiver or
change in repayment rate request.

We will use the information to make a determination regarding overpayment recovery and rate of
repayment. We may also share your information for the following purposes, called routine uses:

1. To employers to assist the Social Security Administration (SSA) in the collection of debt owed
by former beneficiaries and representative payees of Social Security payments who received
an overpayment and owe a delinquent debt to the SSA; and

2. To another Federal agency that has asked SSA to effect an administrative offset under
common law or under 31 U.S.C. 3716 to help collect a debt owed the United States.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORNs) 60-0094, entitled Recovery of Overpayments, Accounting and Reporting/Debt
Management System; 60-0231, entitled Financial Transactions of SSA Accounting and Finance
Offices; and 60-0320, entitled Electronic Disability Claims File. Additional information and a
full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement- This information collection meets the requirements of 44 U.S.
C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to
answer these questions unless we display a valid Office of Management and Budget control number.
We estimate that it will take about 2 hours to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to:SSA 6401, Security Blvd,
Baltimore, MD 21235-6401.

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